Provider Demographics
NPI:1104163625
Name:GRIFFITH-MCCLELLAN, SHADESE LISA (LCSW-A,MSW)
Entity type:Individual
Prefix:
First Name:SHADESE
Middle Name:LISA
Last Name:GRIFFITH-MCCLELLAN
Suffix:
Gender:F
Credentials:LCSW-A,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 PHILLIPS LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4747
Mailing Address - Country:US
Mailing Address - Phone:646-938-9097
Mailing Address - Fax:
Practice Address - Street 1:125 OVERHILL DR STE 105
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8232
Practice Address - Country:US
Practice Address - Phone:980-430-9205
Practice Address - Fax:704-799-8949
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-A -21455101YA0400X
NCP0152911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104163625Medicaid